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- - CEFi'IIFICA28 OF nEAT1ii
- STATE OF ALJlB1WA
aA 11 7. A r. cw lie•O. 11 •abtrf •a.d•ac•
COUNTY ~ h• •dwtael•faI ~ -
Calh~ ,.~iATe b• C°uNTr Calhoun
W , iOWN, QR LOCATi I c. IS (:ACE OE DEA c. li N. OR L iON IS RESIpiNCE
- INSIDE CITS~Y lIMITST iNSID~~EyyCfTY LIMiiST
r _ YEt NOO p d YEa$ NOu
d. M!< OF Ilf •cf i• Aeapa•1, 4ir• afre•t •ddr.sal lEN6iN Of d. STREET ADDRESS
ii03!iTAI Ot ~ STAY IN 1? ON A FARLtT
n+s:r;,noN-_Anni&t~~Qr , 824 S oW Street _ YES_a f.o R~
f:a.?tE CF Brat 1Aiddto L•ai 1, DATE Me•Iw Oar Y•ar
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C:. pe cr pri611 DEATH 11 25 19 / 2
_ Albert Clazence Parris Sr.
SEX COLOR OR RACE GATE OF tIRTH A6 Ifw yarn IiF UNDEU
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Y1 EARlIF U?:'_cs it
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T. MARR!E~~+ NEVER `SARRIED p 4 :rt\dayl I
;1 ~ {51 - , wiCOWED Q D!YC[CED O~ 8-2U-1895 ( }.IA•etla ~ D.}: ~ Noon Fr~~
' USUAL CCCUMTION iG~re t'w~ of 1CD. KIND OF BUSINESS OR 1 t. R!RTMfLACE Iif•h or for•iya co:,atry; I2. CI112Et\ Of Yrl-~a' COU'~: FY?
-ori core drri~q molt of wriiwq lii•1 IN'JL~SiRY ~ .
' ~ ~ CA ~ ~ li~t1
~ Fa.T1tER'S
hA?iE Is. MOTNER'•_ MAIDEN
NAME ~ lo•. N~.ME OF SURYlY1NG SFOUSE
i+`arner David Parris _ ~ A~'die Austin- ~ Nellie Pazzis
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~ :S. M•AS GECEASED EvsR IN U. S. AtMEb FORGEST iS. SOC7AL SECURITY NO.' 11. INFORMANT'S NAlAt
I ,yes • •r w?ao.rnl~llf rea, 7ir• r.~i.tea of serriul ~ Addr~aa Albezt C . Parris, Jr, $Oi1
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It. USE O D AT (Enter Defy ow terse per tiM or ti, bt •wd el.l IN RYAL E :w i ~
+ ?ART 1. DEATH WAS CAUSED 1Y: ~~~~,~~y~~:~¢-/J Y ~T ~ ~ ~ ONS~ ANA DEA:K
~ ~ IMMEDIATE CAUSE 1.1 •-~cK- ' ~ - -mac' - `~'~-.G' ;
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t C•wtitroee, ii •wr~ C.~CAt{~O r J__~ _ !.ft..a-, -L~•+--! ~'Z~:Z - -tom
~'c>. qwe r1s. Is DiIE TO (bT._..~_ ~
.hoes cwt. i•1,
' atet:aq t'e• eeden DUE TO Icl_
s ~Z fptnq c•~te teal. _ ,
s O ?ART 11. OTHER SIGNIFICANT COf~DlTtONi CONiRIRUTIN6 70 DEA1N RUT NOT R IAT~ TO HE TERRiINAI DISEASE l1. WAS AUTO/SY
~ CONDITION 6tYEN IN ?ART 11.1 ?ERFORbtEDT
- I YEf O N
~ N~~tr T ?OS. RIt1E NO'N INJYRT . 1 t••iltn tt tK.ry~1 M hrt Il~o .w 11.1 r
i ACCIDENT SUICIDE IiOMfG10E~
~ o o o
~ iCc. TIME OF E{o.r t>t, D•r, Y.•r~ "
z ~ INJURY aaf. -
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J:d- INJURY OCCUttED ~ JOYCE F INJURY 1.. q., in er.~o~t I Mf. ITV, OWN, OR LOCATION COUNTY STATR
wMllE AT NOT W1tILE ~*o. Arre, T•efory, atr•el, olfie•1
wGiK u AT WORK O __~.,c~_
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I 1 ate.-,det: the dece•s•d iruw) 1 ~f M ? ~ .nd (eat s.w~b'~'ylir. ea ~L ~ ~ ~ _
• _~-ate cCCr?red et_-_ ! 1. ~ i 7 ~ wi en 1M d.fi a1•t•d •bw.; •od fo-1Se ti•at o?inr /uo_.Ldq., from 1S. uv.ea r•reeE.
22a.:l6fJ~i? uRE ~ t- tD~gree or fitlel JJb. ADDRESS + 2Je. DATE SivNE~
-Y '
! '~:AC. Gz=FeAT!OY, - i?b. DAiE ~ J:c. NA?~tE OF CEMETERY OR CREMATORY 73d. iOCATON tGtr, fowe, er eoraty) :Star.!
RcMOYAL iSpecifYl
s El;rial _ _ 11-_2_7_-72 , NE:W Sa_lem_ ?iarfet;a,_ GA _ _
- y F„!.fz-AL D!?EC?OtT AODItESS - JS. DATE RECD. tY LCCAI REG. 2t. Rc6!STIuRA'S 516N1TURE
Gr yr wn S vice ~ ~•l _ ~ - Z -
:rice L'a::~han ~.;_~is~fo~. ~rl. _
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